Using qualitative and mixed methodologies to explore hierarchy in the operating room

Abstract

In this issue of the Journal, Bould et al. 1 report on the findings of an intriguing mixed methods study that investigates the phenomenon of hierarchy in the operating room setting and its effect on decision-making. In this study, a simulated intraoperative crisis scenario was created in which resident participants were ordered by a faculty anesthesiologist (whom they had not previously met) to transfuse a Jehovah's Witness patient contrary to the patient's explicit written order. This scenario took place in either a ''high'' or a ''low hierarchy'' operating room environment where scripted interactions between team members were either formal and impersonal or informal and friendly. The simulations were video recorded, and the behaviours of the residents in challenging the order to transfuse were rated using the modified Advocacy Inquiry Scale (mAIS). 2 The results of this quantitative component of their study had been previously reported. 2 This present paper focuses on the findings from the qualitative part of their study where the residents were subsequently debriefed and interviewed post-simulation. As qualitative and mixed methods studies are relatively less common in anesthesia research, it is useful to review these approaches prior to commenting further on the findings of this study.Healthcare research has been dominated traditionally by quantitative research; recently, however, qualitative research has become increasingly used. [3][4][5] Of the various qualitative methodologies, the grounded theory methodology has gained the most popularity in healthcare research, due in part to its focus on generating theory from the empirical data and its specified methodological procedures. [3][4][5] While both quantitative and qualitative research aim to represent phenomena accurately, they approach this task from different epistemological frameworks, purposes, and methodological procedures. 6,7